Ayesha Sultana was a cheerful 14-year-old who had a normal, happy life. She lived with her mother and older brother, her father having passed on when she was a baby. She loved school and was popular with classmates and teachers alike.
One morning she suddenly began to weep, saying “I’m scared” over and over, and refused to go to school. I met her later that morning. Her face was tear-stained and her expression was like that of a hunted animal, terrified and confused. She relaxed a bit as we started talking. She was scared because she sometimes heard noises - like a ringing sound or a whisper - when there was no source for them to come from. This had happened a few times in the past few months, usually before exams, but had never been loud enough, or lasted long enough, to scare her. This morning it had been very loud, “like there were bells jangling inside my head”.
Vybhav was in his early twenties when he presented with a history of episodes of suddenly feeling that his hands had disappeared. If he was driving he had to stop because he had no hands to drive with! Or the floor would suddenly undulate like a bed-sheet on a clothesline on a windy day, and he would have to stop walking. He was frightened by these bizarre perceptions and had consulted a physician and an ophthalmologist. Clinical examination and relevant investigations had turned up nothing to explain his symptoms.
In such cases, initial treatment is directed towards control of the frightening symptoms. Both Ayesha and Vybhav responded well to small doses of an antipsychotic medication. They were able to return to their normal lives, though they had to continue taking medicines. Once their immediate fear is controlled, people experiencing them can process what they are going through, allowing the doctor to access their thoughts and perceptions and make a final diagnosis.
Ayesha is now in the second year of her Bachelor’s course. Over the next four years she occasionally experienced the same symptoms, but they were infrequent and of a much lower intensity. She continued to receive a maintenance dose of medication during that period. Two years ago, at eighteen, she developed severe mood swings and a mood stabilizer was added. Last week her mother called to say that Ayesha has again started complaining of intense fear and is refusing to go to college, something that has not happened in the last six years.
Vybhav continued to take medication and meet me once in three months for the next one year. The strange symptoms completely disappeared. He developed new symptoms and the clinical picture became clearer. A final diagnosis was made and he was started on appropriate medication. He has been taking this medication for the last ten years (some types of mental illness need lifelong treatment). He did try stopping it for a few days on his own, but resumed due to reappearance of symptoms. He is married, runs a successful business and is, in short, leading a perfectly normal life.
Ayesha and Vybhav are the kind of people whose early symptoms need to be monitored regularly. They do not meet the criteria for a definite diagnosis when they are first seen, as the clinical picture is still evolving. Nevertheless, they respond well to medications given on the basis of a provisional diagnosis, and their lives are disrupted much less than they would otherwise be.
Serial mental state examinations help reach a diagnosis over time. Sometimes all symptoms disappear in a few weeks or months, obviating the need for further treatment. A lot of the time, though, the outcome is not so favorable. In Ayesha’s case, the course has fluctuated, somewhat stabilizing for four years, followed by new symptoms, stabilizing again for two years until last week’s developments. This is often the case with younger people.
Giving someone a diagnostic label on the basis of inadequate information serves no purpose and may even hurt the young people and their families. Long-term follow-up makes it possible to analyze new symptoms, reach a diagnosis and modify treatment accordingly.
In this series Dr Shyamala Vatsa highlights the fact that teenage changes can mask incipient mental health problems. These articles show how early symptoms of mental disorder can be taken for ordinary teenage behavior. As illustrated by the stories of young people who have suffered unnecessarily, it is important for friends and family to recognize when a behavior is outside normal limits, and seek help before things spin out of control.
Dr Shyamala Vatsa is a Bangalore-based psychiatrist who has been practicing for over twenty years. If you have any comments or queries you would like to share, please write to her at firstname.lastname@example.org